An admirable series. 1991: A US Air heavy lands on a runway at Los
Angeles International Airport and immediately collides with a smaller
commuter airliner waiting for clearing to take off. The fuel explodes.
Everyone on the commuter flight dies. Many on the larger airplane also
die. One of the escapees is David Koch, of Koch brothers fame, who
seems entirely human and a bit guilty about not having helped anyone
Okay, one airplane is line up, waiting to take off. Another lands
pretty much on top of it. What happened? The crash is traced directly
to an Air Traffic Controller, Robin Wascher, who was kept so busy
maintaining communication with an entirely different airplane that she
simply forgot about the commuter airplane. She was also distracted by
the absence of an important paper record -- a "strip" -- that should
have been sent to her.
And here's where the program excels. One of the talking heads comments
that it's easy to point the finger at one person and blame her, but
that's never the ultimate cause. An analyst has to overcome the impulse
to let all the responsibility rest on one face and one name, and
examine the causes of the mistake.
It's an impulse that few of us can resist. Who wants to delve into
network dynamics when he can simply say, "SHE DID IT"? Of course she
did do it. She left the trade at once and never worked as an ATC again.
But why did the mistake happen? For one thing, Los Angeles is one of
the busiest airports in the world, with about one near collision every
months. Wascher couldn't see the Sky West commuter sitting on the
runway because the line of sight was blocked by a pole with a bright
light on it. The ground surface radar, which keeps track of who's where
on the runways and intersections, was never reliable and was down that
night. Requests for repair or replacement were overlooked.
So why didn't the pilots of the US Air see the smaller airplane? It had
its navigation lights on but was not required to use the more salient
strobe lights. The lights that were displayed resembled many other
lights at the airport. The ATSB investigators placed an identical
airplane on the runway, then took off at night in a helicopter and
simulated the approach of US Air. They couldn't see the commuter plane.
Improvements in the technology were made and a new control tower built,
but runway incursions continued with many near misses. The latest
improvement is a series of lights resembling traffic lights than tell
the pilot when he can go and when he can't.
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